Essentials of 4-Handed DentistryEssentials of 4-Handed Dentistry
Dena 320Dena 320
Lesson IIILesson III
Deborah BellDeborah Bell
Major Goal in the Practice of Major Goal in the Practice of DentistryDentistry
Deliver high quality serviceDeliver high quality service
Deliver service as efficiently as possibleDeliver service as efficiently as possible
Dental Procedures May Be Dental Procedures May Be Divided Into 3 PartsDivided Into 3 Parts
PreparationPreparation Patient treatmentPatient treatment Clean upClean up
– A second assistant may be utilized to prepare A second assistant may be utilized to prepare and clean up allowing first assistant to beand clean up allowing first assistant to be
– Full time chairsideFull time chairside– Thus no down time between patientsThus no down time between patients
Concepts important to teamwork Concepts important to teamwork dentistrydentistry
Done in seated positionDone in seated position Patient positionPatient position Work area usedWork area used Operatory equipmentOperatory equipment Availability of second assistantAvailability of second assistant Instrument exchange Instrument exchange Use of oral evacuatorUse of oral evacuator
2 Basic Issues of Interest in 2 Basic Issues of Interest in DentistryDentistry
Minimizing stress and fatigue for the dentistMinimizing stress and fatigue for the dentist Increase productivity while maintaining Increase productivity while maintaining
high quality standardshigh quality standards
Dentistry is stressful and Dentistry is stressful and fatiguingfatiguing
Operator must maintain high level of Operator must maintain high level of concentrationconcentration
Keep a high level of clinical excellence by Keep a high level of clinical excellence by his/her ability tohis/her ability to– Meet variety of patient needsMeet variety of patient needs– Perform delicate skills with limited accessPerform delicate skills with limited access– Manage schedule and the practice Manage schedule and the practice
4-Handed Dentistry Reduces 4-Handed Dentistry Reduces StressStress
Increasing efficiencyIncreasing efficiency Thus increasing productivity to meet Thus increasing productivity to meet
demands of publicdemands of public
Concept of 4-Handed DentistryConcept of 4-Handed Dentistry
Operating in a seated positionOperating in a seated position Employing the skills of a trained assistantEmploying the skills of a trained assistant Organizing every component of the Organizing every component of the
practicepractice Simplifying all tasks to the maximumSimplifying all tasks to the maximum
3 Major Aspects of 4-Handed 3 Major Aspects of 4-Handed DentistryDentistry
Work simplificationWork simplification Motion economyMotion economy Body mechanicsBody mechanics
Motion EconomyMotion Economy
Conservation of motionConservation of motion– Movements consume time and produce fatigueMovements consume time and produce fatigue
Eliminate excess harmful motionEliminate excess harmful motion
Classification of MovementsClassification of Movements
Class IClass I– Only fingersOnly fingers
» Signal for instrument transferSignal for instrument transfer
Class IIClass II– Fingers and wristFingers and wrist
» Use of an instrumentUse of an instrument
Class IIIClass III– Finger, wrist and elbowFinger, wrist and elbow
» Mix amalgam, activating chair buttonsMix amalgam, activating chair buttons
Class IVClass IV– Entire arm from shoulderEntire arm from shoulder
» Adjusting light, rubber dam placementAdjusting light, rubber dam placement
Class VClass V– Entire arm and twisting of the trunkEntire arm and twisting of the trunk
Class IV and VClass IV and V
Most fatiguingMost fatiguing Requires to look away from field then Requires to look away from field then
refocusrefocus Results: eyestrain and headachesResults: eyestrain and headaches
Class I, II, IIIClass I, II, III
Preferred for DA and DrPreferred for DA and Dr Involves less muscle activity and saves timeInvolves less muscle activity and saves time Allows eye contact concentrated on Allows eye contact concentrated on
operative fieldoperative field
Positioning the Patient and the Positioning the Patient and the Operative TeamOperative Team
Objectives of a Favorable Seated Objectives of a Favorable Seated PositionPosition
Access to the operative fieldAccess to the operative field Good visibilityGood visibility Comfort for the operative teamComfort for the operative team Relative comfort and safety for the patientRelative comfort and safety for the patient
Zones of ActivityZones of Activity
Patient in a supine positionPatient in a supine position
Using center of patients face as a Using center of patients face as a clockclock
Zones designated as timeZones designated as time
Right Handed Operator Right Handed Operator
Operator zoneOperator zone– 7 – 12o’clock7 – 12o’clock
Static zoneStatic zone– 12 – 2o’clock12 – 2o’clock
Assistants zoneAssistants zone– 2 – 4 o’clock2 – 4 o’clock
Transfer zoneTransfer zone– 4 – 7 o’clock4 – 7 o’clock
Left – Handed OperatorLeft – Handed Operator
Operator zoneOperator zone– 12 - 5 0’clock12 - 5 0’clock
Transfer zoneTransfer zone– 5 – 8 o’clock5 – 8 o’clock
Assistant zoneAssistant zone– 8 – 10 o’clock8 – 10 o’clock
Static zoneStatic zone– 10 – 12 o’clock10 – 12 o’clock
Positioning the OperatorPositioning the Operator
Work environment is adapted to the Work environment is adapted to the operatoroperator
Operator positioned first thenOperator positioned first then– Patient Patient – AssistantAssistant– equipmentequipment
Characteristics of Balance Characteristics of Balance Posture for OperatorPosture for Operator
Operators thighs parallel to floorOperators thighs parallel to floor Entire surface of seat used to support Entire surface of seat used to support
weightweight Backrest supports back without interferenceBackrest supports back without interference Forearms parallel to floor when hands are in Forearms parallel to floor when hands are in
operative positionoperative position Elbows close to the bodyElbows close to the body Back and neck reasonably upright with top Back and neck reasonably upright with top
of shoulders parallel to floorof shoulders parallel to floor
Distance of approximately 14 – 18 inches Distance of approximately 14 – 18 inches between the operator’s nose and the patients between the operator’s nose and the patients oral cavity maintainedoral cavity maintained
Operative field is operators midlineOperative field is operators midline
Positioning the Patient in the Positioning the Patient in the Working PositionWorking Position
Oral Cavity at height of operator’s elbowOral Cavity at height of operator’s elbow Head placed at upper end of chair and Head placed at upper end of chair and
slightly to operators side of chairslightly to operators side of chair All patients are seated from the head downAll patients are seated from the head down
Steps to position a PatientSteps to position a Patient
Adjust back approximately 60 degrees to Adjust back approximately 60 degrees to verticalvertical
Raise chair to height patient can easily be Raise chair to height patient can easily be seatedseated
Raise arm of chairRaise arm of chair Once patient is seatedOnce patient is seated
– Armrest downArmrest down– Raise chair approximately 10 inches to allow Raise chair approximately 10 inches to allow
Dr. to position himselfDr. to position himself
Tilt seat portion back so foot rest is raised Tilt seat portion back so foot rest is raised approximately 6 to 8 inchesapproximately 6 to 8 inches
Lower back of the chair until patient is Lower back of the chair until patient is about ½ way toward a horizontal positionabout ½ way toward a horizontal position– Pause to allow patient to adjustPause to allow patient to adjust
Continue lower chair back until following Continue lower chair back until following relationships existrelationships exist– Imaginary line from patients chin to the top of Imaginary line from patients chin to the top of
ankles is parallel with floorankles is parallel with floor
Once seated – Observe PatientOnce seated – Observe Patient
Lying flat with little bending at waistLying flat with little bending at waist Similar to sleep positionSimilar to sleep position Legs slightly lower than head – if higher Legs slightly lower than head – if higher
might cause – pt. Anxiety/circulation might cause – pt. Anxiety/circulation problems.problems.
Patient in supine positionPatient in supine position
– Plane of the patients forehead is also parallel Plane of the patients forehead is also parallel with the floorwith the floor
Lower chair to operators lapLower chair to operators lap– Approximately 1 inch above knees of operatorApproximately 1 inch above knees of operator
Supine PositionSupine Position
Universal position for all working positionsUniversal position for all working positions Patient is lying down facing upwardsPatient is lying down facing upwards Slight modifications only allowed as Slight modifications only allowed as
patients needs are assessedpatients needs are assessed
Patient DismissalPatient Dismissal
Patient dismissal should be accomplished Patient dismissal should be accomplished by reversing the steps of seating the patientby reversing the steps of seating the patient
Remember to pause for the patient on the Remember to pause for the patient on the way up as wellway up as well
Most important patient dismissal precautionMost important patient dismissal precaution– Encourage the patient to remain seated to Encourage the patient to remain seated to
reestablish their equilibrium reestablish their equilibrium
Positioning the AssistantPositioning the Assistant
Must be able to see and have favorable Must be able to see and have favorable access to be able toaccess to be able to– Retract tissuesRetract tissues– Evacuate fluidsEvacuate fluids– View to anticipate needs of operatorView to anticipate needs of operator– Maintain clear fieldMaintain clear field
Position of AssistantPosition of Assistant
3 o’clock position for all quadrants3 o’clock position for all quadrants– Right handed operator Right handed operator
9 o’clock position for all quadrants9 o’clock position for all quadrants– Left handed operatorLeft handed operator
Stool positioned so edge toward the top of patients Stool positioned so edge toward the top of patients head is in line with the patients oral cavityhead is in line with the patients oral cavity
Stool as close to chair as possibleStool as close to chair as possible Stool elevated to top of assistants head is 4 – 6 Stool elevated to top of assistants head is 4 – 6
inches higher than the dentistinches higher than the dentist
Back erectBack erect Body support arm adjusted to support upper Body support arm adjusted to support upper
body just under rib cagebody just under rib cage If stool positioned properly mobile cart can If stool positioned properly mobile cart can
be pulled over lapbe pulled over lap– Approximately 2 inches below elbowsApproximately 2 inches below elbows
Work SimplificationWork Simplification
Major advantage – Doctors HealthMajor advantage – Doctors Health Definition – finding an easier way to do a Definition – finding an easier way to do a
task more efficiently – less pt. Treatment task more efficiently – less pt. Treatment time spenttime spent
Work simplification studies indicate 4 areas Work simplification studies indicate 4 areas to make dentistry delivery easierto make dentistry delivery easier
Rearrangement of instruments and Rearrangement of instruments and equipmentequipment
CombinationCombination EliminationElimination Thus simplificationThus simplification
RearrangementRearrangement
Position all instruments and equipment in Position all instruments and equipment in favorable spot to the team not vice versa to favorable spot to the team not vice versa to minimize movements of teamminimize movements of team
EliminationElimination
Eliminating unnecessary movements, Eliminating unnecessary movements, procedural steps, instruments and procedural steps, instruments and equipmentequipment
Saves time and effortsSaves time and efforts
Examples of EliminationExamples of Elimination
Unnecessary bur changesUnnecessary bur changes– 2 handpieces2 handpieces
Unnecessary instrument exchangeUnnecessary instrument exchange– Use instrument to max. before returningUse instrument to max. before returning
Use supplies and materials that can save Use supplies and materials that can save timetime– Premeasured capsulesPremeasured capsules
Eliminate seldom used itemsEliminate seldom used items– Plan for usual not unusualPlan for usual not unusual
CombinationCombination
Combining stepsCombining steps Combining purpose of equipment and Combining purpose of equipment and
instrumentsinstruments Combining usesCombining uses
Examples of CombinationExamples of Combination
Double ended instrumentsDouble ended instruments Using instruments for more than one Using instruments for more than one
purposepurpose Air/water syringe togetherAir/water syringe together Cements used as base and cementing agentCements used as base and cementing agent
SimplificationSimplification
Last because this should occur after all Last because this should occur after all rearranging, eliminating and combining rearranging, eliminating and combining activities have been completedactivities have been completed
Basic idea – to minimize number of Basic idea – to minimize number of variables in all aspects of the practicevariables in all aspects of the practice
Streamlining process geared to promote Streamlining process geared to promote predictable routines in the work patternpredictable routines in the work pattern
Standardization of Work Standardization of Work ProceduresProcedures
Contributes to effective teamwork by being Contributes to effective teamwork by being able to anticipate the dentist’s needsable to anticipate the dentist’s needs
Contributes to efficiency/productionContributes to efficiency/production
Examples of Standardization for Examples of Standardization for Work SimplificationWork Simplification
Arrange steps into smooth sequenceArrange steps into smooth sequence Use preset trays in order of use from left to Use preset trays in order of use from left to
rightright More than one op.More than one op.
– Each treatment room identical in equipmentEach treatment room identical in equipment» And materialsAnd materials
Sit Down DentistrySit Down Dentistry
Body mechanics/task performance studiesBody mechanics/task performance studies– Seated worker uses 27% less energySeated worker uses 27% less energy– Seated worker has 17% greater life expectancySeated worker has 17% greater life expectancy– Production increases from 33 – 78%Production increases from 33 – 78%
Seated in a balance posture conceptSeated in a balance posture concept ½ the efficiency of a D.A. Is the result of ½ the efficiency of a D.A. Is the result of
working with a well-organized dentist who working with a well-organized dentist who practices 4-handed dentistrypractices 4-handed dentistry
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